What is the most appropriate next step in managing an 18-year-old man with a 3-year history of fatigue and migrating joint pain, who expresses a bleak future and is preoccupied with his symptoms?

Management of an 18-Year-Old with Fatigue, Joint Pain, and Depressive Symptoms

The most appropriate next step in management is to ask about suicidal feelings (option C). This patient's statement that "the future appears bleak" combined with chronic symptoms and fatigue represents a significant suicide risk that requires immediate assessment 1.

Assessment of Suicide Risk

The patient presents with several concerning features that warrant immediate suicide risk assessment:

• Expression that "the future appears bleak"
• Chronic fatigue lasting 3 years
• Preoccupation with symptoms
• Statement of being "too tired to think about it"
• Young age (18 years)

These features collectively suggest depression with possible suicidal ideation, which takes priority over other diagnostic considerations due to the immediate risk to patient safety.

Understanding the Clinical Picture

This patient's presentation shows several important elements:

1. Chronic fatigue and migrating joint pain (3-year history)

   • Persistent symptoms affecting quality of life
   • Multiple medical consultations without resolution (evidenced by the large folder of medical information)

2. Psychological components

   • Preoccupation with symptoms
   • Negative outlook on the future
   • Possible depression

3. Physical findings

   • Low weight (50 kg at 173 cm height)
   • Otherwise normal physical examination

Management Algorithm

1. First priority: Assess suicide risk

   • Ask directly about suicidal thoughts, plans, and intent
   • Determine if immediate psychiatric intervention is needed
   • Establish safety plan if necessary

2. After addressing suicide risk:

   • Evaluate for depression using standardized tools
   • Consider functional neurological disorder (FND) assessment
   • Investigate fatigue and joint pain through targeted testing

3. Address biopsychosocial factors:

   • Evaluate anxiety as a potential symptom precipitating or perpetuating factor 1
   • Consider non-pharmacological interventions for fatigue and pain
   • Assess for trauma history (while respecting boundaries)

Evidence-Based Approach to Fatigue and Pain

The patient's symptoms align with several conditions that feature both fatigue and pain:

• Functional Neurological Disorder: The guidelines highlight that anxiety is common in FND and may act as a symptom precipitating or perpetuating factor 1. Some patients experience physiological consequences of anxiety without recognizing the emotional experience.

• Chronic Fatigue: Evidence suggests that addressing psychological factors is important in managing fatigue. Psychoeducational interventions and cognitive behavioral approaches have shown benefit 1.

• Pain Management: Non-pharmacological interventions including exercise, education, and psychological approaches are recommended for managing chronic pain 1.

Common Pitfalls to Avoid

1. Focusing only on physical symptoms: While Lyme disease testing (option F) might seem reasonable given the joint pain, prioritizing mental health assessment is crucial given the concerning depressive symptoms.

2. Overlooking suicide risk: Statements about bleak future should never be ignored, even when physical symptoms are prominent.

3. Premature diagnostic closure: While the patient's extensive medical records suggest previous workups, avoiding premature conclusions about the cause of symptoms is important.

4. Dismissing symptoms as "just psychological": The guidelines emphasize that fatigue and pain often have multiple interacting biological, psychological, and social factors 1.

After addressing the immediate suicide risk, a comprehensive approach to the patient's fatigue and pain should include both physical and psychological interventions, with careful monitoring of mental health status throughout treatment.